“We Understand the Prognosis, but We Live with Our Heads in the Clouds”: Understanding Patient and Family Outcome Expectations and Their Influence on Shared Decision Making
Year: 2016
Type: editorial
Abstract: should be noted that a dose of only 50 mg losartan was used in this study, which is not likely high enough to completely antagonize angiotensin.Third, the effect of treating sleep apnea with CPAP continues to have a relatively small effect on BP when all patients are considered, as has been reported previously (3, 6).The difference in BP between the CPAP-treated patients and those receiving no additional therapy was 4.4, 1.9, and 2.5 mm Hg for 24-hour systolic, diastolic, and mean arterial pressure.However, these effects were somewhat larger for the group of patients who used CPAP for more than 4 hours per night (6.5, 3.8, and 4.6 mm Hg for systolic, diastolic, and mean arterial BP).These later values represent a more substantial and clinically important reduction in BP.Thus, the question arises as to whether treating obstructive sleep apnea is an effective method of reducing BP in a hypertensive patient with OSA who is otherwise asymptomatic.I believe this study would suggest that the answer to this question remains "maybe."Only 13% of the patients with OSA achieved optimal BP control on losartan alone, recognizing, however, that only a starting dose of the medication was used.This optimal BP control went up to 25% of patients when CPAP was added, and 38.5% when CPAP was used "adequately" (more than 4 h per night).Thus, most of the patients with OSA in this study would require a higher dose of losartan or the addition of a second antihypertensive drug, even while using CPAP.As we all know, getting patients to use CPAP is a difficult task ( 7), particularly if we are talking about regular CPAP use for the rest of the patient's life, which would be the case if the treatment of hypertension is the goal.However, adherence with long-term pharmacologic management of hypertension is not easy as well.A recent study reported that 12.7% of hypertensive patients were taking none of their antihypertensive medication, and 34.9% were not complying with the entire regimen (8).That is not greatly worse than CPAP adherence.One needs to consider also that in most patients with OSA, hypertension is not the only consequence of the sleepdisordered breathing.Thus, CPAP could contribute to BP control while also improving quality of life and possibly reducing the risk for cardiovascular disease.That combination of outcomes would seem to make CPAP use a worthy goal in the treatment of high BP.
Authors: Laura C. Feemster, J. Randall Curtis
Institutions: University of Washington, VA Puget Sound Health Care System
Language: English
Subfield: Physiology
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W2272256755